Liver Disease Questionnaire for Proposed Insured/Owner

Policy Number
Please fill in block letters & tick appropriate boxes and circles.
A. Personal Information of Proposed Insured / Owner
Last Name First Name Ext Name Middle Name

m m d d y y y y
Date of Birth: / /

B. Liver Disease Questionnaire

1.) History and associated disease(s)
Do you suffer from any of the following diseases?

Hepatitis Type(s) of Hepatitis: ______________ First Diagnosed: m m d d y y y y

Treatment Yes No / /
Current state: ______________________________________________________________

NASH (Nonalcoholic Steatohepatitis) Jaundice Wilson's disease

Liver cirrhosis Hepatocellular carcinoma Hepatosplenomegaly
Haemochromatosis Other Please specify:

2.) When was the diagnosis of Liver Disease made?

m m d d y y y y
Date of Diagnosis: / /
Name of Attending Physician : Specialty of Attending Physician:
Clinic Address : Clinic Hours:
Contact number:

3.) Have you ever been confined because of Liver disease? Yes No If Yes, provide details below.
m m d d y y y y m m d d y y y y
Date of Admission: / / Date of Discharge: / /
Name of Medical Institution:
Address : _______________________________________________ Contact number:
Name of Attending Physician/s :

4.) What are your medications?

Name of Drug Dosage Date Started
(include Preparation) m m d d y y y y
/ /
/ /
/ /

5.) Further Laboratory Tests

Has there been any laboratory test to check for Hepatitis B and /or C? Yes No
If yes, please provide further details:
Hepatitis B serology: _____________________________________________________________________
Hepatitis C serology: _____________________________________________________________________

6.) Liver Biopsy

Has a liver biopsy been performed? Yes No
If yes, please provide further details:
Cirrhosis Fibrosis No pathological result
Degree of fibrosis: _______________________________________________________________________
Degree of inflammation: __________________________________________________________________

7.) Do you have any other existing medical condition or disease? Yes No
If yes, provide details.
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8.) Is there anyone else in the family who has Liver disease? Yes No
If yes, provide degree of relationship.

9.) Have you ever been absent or off from school or work due to liver disease? Yes No If yes, provide details.
m m d d y y y y
Number of times in a year: Date of last occurrence: / /

C. Affirmation Section
I hereby declare that the answers/statements that I have made to this questio nnaire are true and accurate representatio ns o f my health co nditio n. Sho uld FWD need additio nal info rmatio n,
I hereby autho rized the abo ve mentio ned physician, surgeo n, o r medical institutio n to pro vide FWD o r its autho rized representative, the M edical Info rmatio n B ureau o r any go vernment
agency requiring such with info rmatio n o r do cuments pertaining to my health co nditio n. Further, I am fully aware that statements made to this questio nnaire shall fo rm part o f and be the
basis fo r the issuance o f the po licy bearing the same number as stated abo ve.
m m d d y y y y
Place Signed Date: / /

Signature over Printed Name of Proposed Insured / Owner

LIVERQV206112014